Cigarette smoking, the main way we take in nicotine, is the single greatest cause of preventable diseases (these are the progressive, serious diseases) and probably creates the most difficult addiction of the commonly used drugs. Smoking is a high-priced addictive pleasure (and sometimes displeasure) that is costly, not only in dollars but in lives as well.

In the United States alone, cigarette smoking causes a third to a half million deaths per year (over 1,000 per day) and is responsible for about 25 percent of the cancer deaths and 30–40 percent of the coronary heart disease. It also increases the incidence of atherosclerosis, strokes, and peripheral vascular disease. Diseases of the lungs—colds, flus, acute bronchitis, pneumonia, COPD (chronic obstructive pulmonary disease), which includes emphysema and chronic bronchitis, and lung cancer—are all much more common in smokers. Other infections or allergies are also prevalent, and rapid aging of the body and especially the skin results from the generally poor oxygenation of tissues and the other chemicals and physiological effects of regular cigarette smoking.

Smoking clearly decreases life expectancy for all age groups. One-pack-a-day smokers double their chances of death between the ages of 50 and 60, while two-packers triple theirs. And smoking also affects the life expectancy of nonsmokers close to them in heart and proximity. Of all the common drugs, nicotine intake from cigarette smoking clearly has the least benefits and the most negative consequences.

The estimated cost of smoking is somewhere between $50 and $100 billion a year. Some 650 billion cigarettes are sold yearly in the United States in this $18–25 billion megabusiness. Marlboros and Winstons top the list with nearly 50 percent of the market. The 650 billion count averages about 4,000 cigarettes per year per person over age 18. Recent estimates suggest that about 38 percent of the over-18 population in the United States smoke. Percentages of adult smokers are even much higher in most European countries and some parts of Asia. In addition to the cost of the cigarettes, there are many billions spent medically to treat the problems that afflict smokers and many more billions in lost work and productivity caused from diseases generated by smoking.

I am happy to say that now only 10 percent of doctors in the United States smoke; the percentage used to be much higher. The number of cigarette smokers, which for many years has increased steadily, is tapering off somewhat. Worldwide however, there is still about a 2–3 percent yearly rise in smokers. The dangers of nicotine and smoking are now so generally accepted and well documented that it would seem that more people would be stopping or not even starting. The fact that fewer doctors smoke (or admit that they smoke) is at least representative of these health dangers. People want doctors to do healthy things and to set healthy examples.

Since most nicotine intake is from smoking cigarettes, that is the focus of this section. Cigar and pipe smoking, chewing tobacco, and snuff also pose some health risks, but far less than cigarette smoking. The regularly inhaled smoke contains tars composed of literally thousands of chemicals, including those used in tobacco cultivation as well as in cigarette making. These agents add other health risks in addition to the nicotine, which directly acts on the cardiovascular and nervous systems. There are over 30 potentially carcinogenic chemicals contained in cigarette smoke.

Tobacco comes from a large-leafed nightshade, or Solanaceae, plant. It is one of a few plants that contain the psychoactive alkaloid, nicotine. Tobacco causes joint pain in some people; this seems correlated to the theory that arthritis is in part a result of an allergy to the nightshades, which also include potatoes, tomatoes, eggplant, and peppers.

Nicotine has been widely used throughout history, first in North America. Supposedly, Columbus and other visitors were interested in it and carried some tobacco and seeds back to Europe, where its use caught on rapidly and eventually spread to Africa and the Orient. Tobacco was outlawed by several countries during the early 1600s, but to no avail; then the governments eventually found ways to profit from its use. This seems fair, since it costs them in the long run with lost health and productivity of their people. The addictive nature of nicotine has been clear for hundreds of years, as people have found ways to smoke during poverty, famine, and war.

Sigmund Freud was fascinated with tobacco and obsessed with cigars (smoking more than 20 a day). He fought his addiction to nicotine (and apparently to cocaine) through much of his life, though he experienced mouth cancer, angina pain, and multiple surgeries. Freud’s dance with death and his inability to get off tobacco probably generated his theory of Thanatos, our deep subconscious longing for death, manifested in part by our destructive habits.

Smoking is clearly a deadly pastime. Its addictive nature is revealed by the fact that many strong-minded and strong-willed people cannot stop smoking, even if they are otherwise health conscious or faced with death. And most smokers, over 80 percent, declare that they want to stop smoking, and plan to at some time. In my years working in hospitals, I saw the most bizarre smoking phenomena, such as lung cancer or emphysema patients smoking between ventilator treatments or patients who breathed through tubes in their necks after tracheostomies, actually putting cigarettes into the tubes to inhale. Our passion for puffing is persistent.
Nicotine is the addictive drug found in tobacco. Even though some people start smoking for the image or the ritual, they may easily become hooked. The "up" feeling that smoking produces is likely correlated with the increased blood pressure and heart rate, as well as the production of fatty acids, steroids and possibly other hormones or neurotransmitters. Nicotine mimics acetylcholine, which then improves alertness, memory, and learning capacity. Other neurotransmitter stimulation of norepinephrine and endorphins by nicotine may help balance moods and increase energy. The liver’s increase in glycogen release gives a satisfying lift in the blood sugar.
The addiction to nicotine is probably stronger than addictions to most other drugs. The initial irritating effects progress to chronic irritations, yet these are covered by the physiological and, in many instances, the psychological need (although the latter is usually secondary). Heroin addicts and people addicted to other powerful drugs have commonly referred to nicotine as the hardest drug to kick. The American Psychiatric Association has described smoking as an "organic mental disorder." Their statistics suggest that around 50 percent of people cannot stop when they try to and that, of the people who do stop, about 75 percent of them begin again within one year.

Are There Benefits in Smoking?
There obviously must be a few, or so many people would not smoke, but it is very clear that the risks outweigh the pleasures by far. Many people find smoking relaxing, but this may be a result of calming the hyperactive withdrawal symptoms. People do experience mental stimulation and improvement of hand-to-eye coordination and work activities, probably as result of nicotine’s vascular-neurological stimulation. The benefits that smokers experience were well described in Dr. Tom Ferguson’s book, The Smoker’s Book of Health, from his interviews with hundreds of smokers. They felt better able to deal with stress and to unwind and relax. Smoking helped control their moods, improve concentration and energy levels, especially with fatigue, and reduce withdrawal symptoms, obviously. Social comfort, work breaks, reduced pain and anxiety, increased pleasure, and less boredom were also correlates for some who smoked. Smoking also usually reduces the appetite and taste for food, so it may help people to reduce food intake, a positive step for the weight conscious. The average smoker weighs six to eight pounds less than the nonsmoker. In Life Extension, Sandy Shaw and Durk Pearson note that nicotine seems to reduce distraction by outside stimuli in people working in highly stimulating environments—that is, it desensitizes people. I see this as creating a smoke screen that protects us from relating to others and keeps us in our own world. It is clear that people who work in crowded, noisy, busy offices with other workers, computers, machines running, and lots of hustle and bustle tend to smoke more frequently than do workers in more private situations.

Yet, most employers now know there is a distinct disadvantage in hiring smokers. The smoke interferes with office morale, and it is more costly. Some estimates suggest that employing a smoker costs businesses nearly 5,000 yearly. This cost comes from increased absenteeism, death risk, incident of accidents, and property damage or cleaning bills from smoke, as well as less productivity. Dr. Ferguson points out that most people are aware of this and the health hazards of nicotine and cigarette smoke. They clearly want to quit, but have not found a way to get rid of withdrawal and craving. Finding ways to reduce stress and clear those conditioned responses to want to smoke takes a great deal of effort.

What Does Nicotine Do?
Nicotine, the active and addictive ingredient of tobacco, is a mild central nervous system stimulant and a stronger cardiovascular system stimulant. It constricts blood vessels, increasing the blood pressure and stimulating the heart, and raises the blood fat levels. In its liquid form, nicotine is a powerful poison—the injection of even one drop would be deadly. It is the nicotine, not the smoke, that causes people to continue to smoke cigarettes, but it is the cigarette smoke that causes many of the problems.

Cigarette smoke is a combination of lethal gases—carbon monoxide, hydrogen cyanide, and nitrogen and sulfur oxides—and tars, which contain an estimated 4,000 chemicals. Some of these chemical agents are introduced by current tobacco manufacturing processes. Although tobacco has been smoked for centuries, only recently has it moved from the naturally grown and dried process. It appears that in the last century the negative effects of smoking have skyrocketed. My belief, which is shared by many authorities, is that much of the added risk is produced by the chemical treatment and unnatural processing of tobacco. The little research that has been done on this (it is not sponsored by the industry) suggests that natural tobacco poses much less cancer risk, as well as cardiovascular disease risk, though this is predominately from the nicotine, which is not changed by processing.

Dangers in modern tobacco products include pesticides used during growth and chemicals added to the tobacco to make it burn better or taste different. Chemicals added to the leaves and papers to enhance burning are among the major causes of fire deaths in this country, as cigarettes continue to burn after they have been put down. The forced burning also makes people smoke more of each cigarette in order to complete it. Sugar curing and rapid flue drying are also associated with increased toxicity of cigarettes. Kerosene heat drying contaminates the tobacco with another toxic hydrocarbon. Using a natural tobacco, such as some imported from France or Germany and a few U.S.-made cigarettes (possibly Shermans and More), may reduce the smoking risk. If a cigarette does not go out when left alone, it has been chemically treated.

Other toxic contaminants in cigarettes include cadmium (which affects the kidneys, arteries, and blood pressure), lead, arsenic, cyanide, and nickel. Dioxin, the most toxic pesticide chemical known to date, has been found in cigarettes. Acetonitrile, another pesticide, is also found in tobacco. The nitrogen gases from cigarettes generate carcinogenic nitrosamines in the body tissues. The tars in smoke contain polynuclear aromatic hydrocarbons (PAH), carcinogenic materials that bind with cellular DNA to cause damage. Antioxidant therapy, particularly with vitamin C, is protective against both PAH and nitrosamines, and extra C also blocks the irritating effects of smoke. Smoking itself reduces vitamin C absorption; blood levels of ascorbic acid average about 30–40 percent lower in smokers than in nonsmokers.

Elson M. Haas, MD is founder & Director of the Preventive Medical Center of Marin (since 1984), an Integrated Health Care Facility in San Rafael, CA and author of many books on Health and Nutrition, including ...more

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